Q. What is cervical insufficiency or incompetent cervix?A. Normally, a woman’s cervix should open with the beginning of labor after about nine months of pregnancy. But in some women, pressure from a growing fetus in the uterus causes the cervix to open prematurely, leading to a second trimester pregnancy loss of what would otherwise be a normal full term delivery. This loss typically occurs between the 16th and 24th week of pregnancy -- with the vast majority between the 18th and 22nd week of gestation.

Q. How common is cervical insufficiency?A. Incompetent cervix is an infrequent, but devastating condition leading to a pregnancy loss or preterm delivery. The number of women with incompetent cervix is not known. There are many patients with incompetent cervix who have had failed transvaginal cerclage treatment or previous cervical surgery who have simply given up on having additional children.

Q. What are the circumstances that cause this condition?A. Many women first become aware of incompetent cervix after losing their first pregnancy.Most often, the woman has a birth defect that affects the normal shape of the uterus or cervix, though they have no history to indicate the condition.
However, women who may be at risk for cervical insufficiency include those who:

Had a previous dilation and curettage (D & C)

Had a previous surgery for an abnormal PAP smear, such as LEEP (loop electrosurgical excision procedure) or CKC (cold knife conization) that damaged the cervix

While infrequent, incompetent cervix can happen during a later pregnancy after having a previous normal birth.

Q. How do doctors diagnose cervical insufficiency?A. If you are at risk for this condition, your doctor may conduct a pelvic exam or use an ultrasound early in your pregnancy to evaluate the problem. However, many cases of cervical insufficiency are not found until after a second trimester loss. Women who have already had a miscarriage because of this problem will likely have the same outcome in future pregnancies if they do not seek treatment. This can lead to great stress and emotional suffering for women and couples hoping to become parents.

Q. How is incompetent cervix treated?A. Placement of a cerclage is the standard treatment. A cerclage is basically a band woven of synthetic material that is placed around the cervix to help reinforce it and prevent the amniotic sac from "funneling" down into the cervix prematurely. There are different types of cerclage procedures available.

In a transvaginal cerclage (TVC), the doctor sews the cervix shut with a suture placed through the vagina, usually during the 13th to 14th week of the pregnancy. This method creates a "purse string" around the cervix, which helps reduce the risk of loss. At about 36 weeks, the doctor removes the stitches so that a woman can deliver vaginally. The main drawbacks to this procedure are that it requires bed rest for the remainder of the pregnancy and many of these babies are delivered prematurely -- requiring long hospital stays for the infant. Another disadvantage of the TVC is it needs to be redone with each subsequent pregnancy and it is not always successful, with an approximate 85 percent success rate.

After losing twins to an incompetent cervix, Maryann Gates had a transabdominal cerclage procedure and then carried two pregnancies to term. » Read her story

Another option is a transabdominal cerclage (TAC), in which the doctor operates through a transabdominal incision in the lower abdomen, near the bikini line. This allows placement of a small, woven synthetic band high on the cervix, which supports the cervix, preventing it from opening -- a cause of the second trimester loss. Blood flow from the uterine artery is unaffected. And, unlike a TVC, the TAC does not require bed rest. However, women will need to have a Caesarean section to deliver their baby -- this can be performed through the same bikini line incision that the surgeon used to place the cerclage. The band is safe to stay in the body and, once it is placed will be just as successful during later pregnancies.

Dr. Haney and his colleagues prefer to place abdominal cerclages for pregnant patients in the 10th week of gestation, when the risk to the patient and fetus are minimal. TACs can be placed up to 16 weeks of gestation, if necessary.

Q. Can a transabdominal cerclage be performed before pregnancy?A. Yes, in fact, a unique aspect of our cervical insufficiency approach is that the majority of our patients have their transabdominal cerclage placed before pregnancy. Most believe that Dr. Haney has placed more pre-pregnancy cerclages than any other surgeon in the nation. The advantages of the prepregnancy transabdominal cerclage are that it eliminates any risk to the fetus and enables the cerclage to be placed as high as possible around the cervix. The TAC procedure is the ideal treatment for women with multiple losses due to a damaged or malformed cervix or a failed transvaginal cerclage.

As with any surgery, there are some risks to cerclage procedures. A woman should discuss the potential risks and benefits with her doctor.

Q. What are the success rates of cerclage treatments?A. Typically, 80-85 percent of women who have a TVC deliver a viable infant. They require bed rest and many women deliver preterm which may lead to their baby staying in the neonatal intensive care unit for an extensive time.

Aubrey Polatty was born after her mom, Mandy, had a TAC at the University of Chicago Medical Center. » Learn more

The TAC yields a term delivery by C-section in more than 95% of women -- many of whom have had multiple losses as a result of their weakened cervix and who have already had failed TVC procedures. Women who have had TAC procedures do not require bed rest and most deliver at full term, avoiding the hazards of a premature birth.

Although TAC has a significantly higher success rate, it is much less commonly performed. Women who are interested in this type of cerclage should seek out physicians who have extensive experience with the procedure.